CATEGORY AUSTRALASIAN DENTIST 67 CLINICAL switch followed resulting in the detection of much higher numbers of dispersed planktons, compared to perhaps 2% or repetitive negative culture recorded from passive swabs (Tuttle et al., 2011). Similarly, 22% live bacterial culture was recorded when subjecting biofilm-infected hip prostheses to the disturbance delivered by ultrasonication (Tunney et al., 1998). SEM provided high-magnification spatial images of bacteria located on bone surfaces and within the biofilm of bone from samples of both patients and allowed good visualization of the bacteria and biofilms (Alhede et al., 2012). This evidence could then be integrated with clinical and radiographic observations in association with microbiome analysis to provide correlated evidence for the biofilm-based infectious disease pathogenesis (Costerton, 2005). In a disturbance profile of chronic pathology, SEM visually confirmed bacterial biofilm disease persistence in the jawbone 9 months after extraction. Furthermore, SEM provides visual corroborative evidence of the altered bacterial presence in health recovery and population shift. This further demonstrated that bacteria naturally exist in the biofilm mode in health and disease and are not eradicated with the resolution of chronic pathologic lesions. It further supports the hypothesis that there is a routine commensal (resident) live biofilm. Surgical drilling debridements to vascularised margins beyond sclerotic encapsulation in both patient cases in this study progressively shifted and replaced live biofilms that were a result of pathogenic bacteria with live biofilms that were a result of less pathogenic or non-pathogenic bacteria. Circumvention of ubiquitous pathologic bacterial biofilms (Weinstein and Darouiche, 2001; Deva et al., 2013) as opposed to adherence to the sterile bone paradigm requiring debridement to remove all bacteria and bacterial biofilm (Schultz et al., 2017). To the best of our knowledge, SEM has not previously shown evidence of live biofilm population shift in a samesite, longitudinal case in jawbone biofilm infection (Case 2), corroborated by microbiome analysis recording 7 phyla shift between 9 and 12 months post extraction, clinical and radiographic evidence. Previous studies using SEM in dentistry recorded polymicrobial biofilms in a lower molar site 4 years post-extraction despite extended antibiotic administration (Stoodley et al., 2011). In addition, SEM had shown biofilm on resected root surfaces, extruded gutta-percha root filling material, and in sulfur granules from lesions of apical actinomycosis (Leonardo et al., 2007; Signoretti et al., 2011). The development of biofilm-preventing implant surfaces or dampening of the immune response during infection or surgical trauma are talked of as future strategies to avoid host tissue damage and refractory pathologic failure (Ciofu et al., 2022). We have existing answers to both critical issues. Jogging the corporate memory of implant history tells us that ad modum Brånemark had a Swedish naval gun manufacturer (Bofors) "turn' or machine smooth and uniform commercially pure titanium screws with a surface roughness of less than 1 micron (Adell et al., 1981; Brånemark and Albrektsson, 1985). This surface inhibited quorum sensing by biomimicking the smooth and uniform surface topography of pathogen-evading, healthy human cells (Percival et al., 2015). The surface was accessible to cell surface microfluid wash and did not allow stagnation of 1-2 micron bacteria in surface recesses (Mukherjee and Bassler, 2019; Graham and Cady, 2014). When the health ecology of the bone is recovered, there is the potential for beneficial bacterial sRNA to dampen the immune response to surgical trauma/ infection to a recoverable short-term pulse disturbance and return to the predisturbance homeostatic ecologic state (Moriano-Gutierrez et al., 2020). Botton defined ecologic stability as the ability of a system to return to equilibrium after a temporary disturbance (Botton et al., 2006). Beneficial bacterial small sRNA is rarely involved in gene code switches and survival default to persister cell dormancy and relapse infection. The debridementdriven trajectory of the recovery of beneficial health bacteria regulates a dampening or restraint of surgically induced immune response to enable stable symbiont colonization of health microbiota on both biologic and non-biologic surfaces during passive osteoblastic anchorage at the osseointegration interface (MorianoGutierrez et al., 2020, Nelson, 2015). Conclusion Strong evidence is provided supporting the presence of live resident polymicrobial biofilm in apparently healed edentulous human jawbone in health and disease, independent of healing time or surgical intervention. We recovered cellular health homeostasis with evidence of a resident, beneficial, ecologically diverse health microbiota, where sterility was not relevant. Ecologic and internal histologic architectural health of bone may be recovered longitudinally by Regenerative Surgical Debridement (RSD) to a vascularised health margin beyond sclerotic encapsulation by population shift, thereby recovering the microbial diversity and stability of live beneficial health microbiota which may then support a consortial, symbiont colonization of topographically similar abiotic and biotic surfaces in an enduring, passive osteoblastic anchorage, at an inert osseointegration interface, where cellular homeostasis avoids immunomodulation and foreign body response. This is the microbial ecological extension of what P.I Branemark called “Restitution Ad Integrum” and “ad modum Branemark” original osseointegration model. Return to pre-disturbance condition and passive integration of inert commercially pure titanium surfaces without an immunobiological event. To improve osseointegration outcomes and reduce revision numbers, we recommend that eradication of quintessential chronic biofilm infections of bone must occur before implant deployment. This is a clinically viable, biofilm-based methodology, in a new model of biofilm-based osseointegration. Author’s Contributions Stephen Nelson, Honghua Hu, Graham Thomas, and Karen Vickery: Conception and design, acquisition of data, analysis, and interpretation of data. Drafted the critical review for significant intellectual content. Final approval was given for submission. Anita Jacombs: Study design, data collection, and analysis. A critical review of drafted and intellectual content. Final approval was given for submission. Anand Deva: Conception and design analysis and interpretation of data. Final approval was given for submission. Andre John Viljoen: Analysis and interpretation of data drafted and critically reviewed for significant intellectual content. Final approval was given for submission. Institutional Review Board Statement The study was conducted in accordance with the declaration of Helsinki and approved by the University of Sydney human research ethics committee (reference 07-2007/9962). Informed Consent Statement Informed consent was obtained from all subjects involved in the study. Ethics This article is original and contains unpublished material. The corresponding author confirms that all of the other authors have read and approved the manuscript and no ethical issues involved. u For a full list of references, email: gapmagazines@gmail.com
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